30, 15, 22, 19, 20, 21
Unloading during ECPR has not been shown to improve survival and is associated with more complications. Methodologically this is Chapter 30's anchor: where two analyses of the same data disagree, ask which one modelled time. And the 47.2 percent addendum completion rate is the single most consequential denominator in the book's ECPR evidence.
ECPR without mechanical LV unloading. 621 matched pairs.
Ling RR, Chen Y, Low CJW, Agerstrand C, Jung JS, Lim SL, Lorusso R, Mueller T, Okada Y, Tonna JE, Shekar K, Brodie D, MacLaren G, Ramanathan K. Crit Care 2025;29(1):186. DOI 10.1186/s13054-025-05345-3. PMC12063446. READ AS COMPLETE FULL TEXT.
Mechanical LV unloading during the ECPR run (intra-aortic balloon pump or microaxial LVAD), identified by CPT codes. Target trial emulation with confounders selected by a causal directed acyclic graph, multiple imputation with chained equations for missing data, and propensity-score matching.
Observational; residual unmeasured confounding. The registry does NOT record the degree of cardiac dysfunction, the indication for unloading, the timing or duration of unloading, or the timing and indication for PCI. Very few centres sufficiently recorded neurological outcomes at discharge. Immortal time bias is named by the authors: patients must survive long enough to receive the device. Two internal inconsistencies as printed: '1,876 patients (74 percent) had an IHCA' in a cohort of 3,215 (division gives 58.4 percent), and the INCEPTION CI is identical to the primary analysis CI while the point estimate differs. Both reproduced, neither corrected. [VERIFICATION REQUIRED for both.]
No difference in 90-day survival time: HR 0.92 (0.79-1.08). Concordant across IPTW 0.92 (0.82-1.03), complete case 0.99 (0.86-1.15), re-matched 0.92 (0.80-1.06), double-adjusted 0.94 (0.81-1.09), excluding contraindications 0.93 (0.78-1.11), adding PCI 0.94 (0.81-1.09); and across emulated ARREST 0.89 (0.75-1.07), PRAGUE-OHCA 0.92 (0.77-1.10) and INCEPTION 1.05 (0.79-1.08 as printed) eligibility. No difference in favourable functional outcome, OR 1.15 (0.67-1.99). HARMS: renal OR 1.55 (1.16-2.07); cardiovascular 1.60 (1.14-2.26); CNS bleeding 1.75 (1.03-2.96); arrhythmias 1.56 (1.04-2.36); haemolysis 1.85 (1.10-3.09). ECMO duration longer by 23.3 h (8.3-38.4). POST-HOC META-ANALYSIS in the same paper, pooling five other propensity-matched studies (six cohorts, no RCTs) with this one, gave 30-day mortality OR 0.55 (0.35-0.87), graded LOW certainty; IABP 0.66 (0.37-1.17) and mLVAD 0.51 (0.25-1.04) both very low.
Adults receiving ECPR for in-hospital or out-of-hospital cardiac arrest reported to the ELSO Registry 1 Jan 2020 to 31 Dec 2023, first run only. 7,911 ECPR runs reported; 3,736 (47.2 percent) had a valid ECPR addendum; 3,215 analysed. Median centre volume 7 (IQR 3-13); median age 57 (45-66); 68.4 percent male; 44.1 percent shockable; median conventional CPR 44 min (22-58); median ECMO 67 h (21-136).